Nursing Care & Interdisciplinary Roles with Adult Clients in the Emergency/Disaster Environment

1. Nursing Care & Interdisciplinary Roles with Adult Clients in the Emergency/Disaster Environment Kelle Howard, RN, MSN Modified by: Darlene M. Wilson, MSN, RN

2. Objectives • Discuss • Heat Stroke • Cold Related Emergencies • Drowning • Bites/Stings • Poisoning • Agents of Terrorism • Review: with regard to each of the said topics • pathophysiology • causes • manifestations & potential complications • treatment & interventions • interdisciplinary management • Evaluation of Learning • Case studies

3. Heat Stroke:Pathophysiology • Definition • Failure of the hypothalamic regulatory process • Inc. sweating  vasodilatation  Inc. RR  sweat glands stop working  core temp inc. circulatory collapse What makes this temperature so dangerous? What happens to electrolytes? Which ones do you worry about? What are some signs/symptoms of these altered lytes? What are critical labs values for these lytes?

4. Heat Stroke:s/s of electrolyte depletion • Na <120 critical • Change in mental status • Combative, decreased LOC • Hallucinations • Loss of motor control • Cerebral edema & hemorrhage • K <2.8 critical • Hypo-reflexia, muscle weakness • Respiratory depression • Diarrhea • EKG changes

5. Heat Stroke:Causes • Development is directly related to • Amount of time the body temperature is elevated • What are some common causes? Next

6. Heat Stroke:Causes • Strenuous activity in hot/humid environment • High fevers • Clothing that interferes with perspiration • Working in closed areas/prolonged exposure to heat • Drinking alcohol in hot environment

7. Heat Stroke:Manifestations & Complications • What will your patient look like? Next

8. Heat Stroke:Manifestations & Complications • Core temp > 104˚F • AMS • No perspiration • Skin hot, ashen, dry • Dec. BP • Inc. HR • S/S of what?

9. Heat Stroke:Prognosis • Related to: • Age • Length of exposure • Baseline health status • Number of co-morbidities • Which co-morbidities would predispose your patient to heat related emergencies?

10. Heat Stroke:Treatment & Interventions • ABC’s – must stabilize • What assessments/interventions will you perform initially? • What do you think the goal of treatment is? • How would you achieve this goal? Next

11. Heat Stroke:Treatment & Interventions • Goal: • Decrease the core temperature • To what temperature? 102 • Prevent shivering • Why? thorazine • How? – what med is used? Antipsychotic, CNS depression • Attainment: • Remove clothes, wet sheets, large fan (evaporative), ICE water bath (conductive), cool IV fluids • Would you use antipyretics?

12. Heat Stroke:Treatment & Interventions • Monitor for s/s of rhabdomyolysis • What is this? • How would you monitor for this? • Monitor for s/s disseminated intravascular coagulation (DIC) • What is this? • How would you monitor for this?

13. Rhabdomyolysis • Skeletal muscle breakdown • Monitor: ARF – cpk, creatinine, urine • DIC • Pathological activation of coagulation mechanisms • Monitor: • bleeding and bruising • Coags & platelets • ARF – what will you see?

14. Heat Stroke:Interdisciplinary Roles • Who would be involved in this client’s care? • RN • MD - which ones? • RT • SW – why? • Anyone else?

15. Hypothermia:Pathophysiology • Definition • Core temperature less than 95˚F (35˚C) • Core temp <86˚F - severe hypothermia • Core temp <78˚F - death • Heat produced by the body cannot compensate for cold temps of environment • 55%-60% of all body heat is lost as radiant energy • Head, thorax, lungs Dec body temp  peripheral vasoconstriction  shivering &movement  coma results <78˚F

16. Hypothermia:Causes • Exposure to cold temperatures • Inadequate clothing, inexperience • Physical exhaustion • Wet clothes in cold temperatures • Immersion in cold water/near drowning • Age/current health status predispose • What health issues would predispose a patient to hypothermia?

17. Hypothermia:Manifestations & Complications • What will your patient look like?

18. Hypothermia:Manifestations & Complications • Vary dependent upon core temp • Mild (93.2˚F - 96.8˚F) • Lethargy, confusion, behavior changes, minor HR changes, vasoconstriction • Moderate (86˚F – 93.2˚F) • Rigidity, dec HR, dec RR, dec BP, hypovolemia, metabolic & resp acidosis, profound vasoconstriction, rhabdomyolysis • Shivering usually disappears at 92˚F • **What about each system? • Profound/(Severe) (<86˚F) • Person appears dead – attempt to re-warm to 90˚F • Reflexes & vitals very slow • Profound bradycardia, asystole 64.4˚F, or Vfib 71.6˚F – usual cause of death? Next

19. Hypothermia: ModerateManifestations & Complications • Hematologic • HCT inc. as volume dec.  • cold blood thickens, thrombus occurs • Neuro • Stroke  • lack of blood flow due to vasoconstriction/thrombus • Cardiac • Irritable myocardium  • atrial & ventricular fibrillation, MI • Respiratory • PE • Acidosis  • lactic acid builds up  anaerobic metabolism  metabolic acidosis • Renal • Dec blood flow, dehydration, rhabdomyolysis  • Acute Kidney Injury

20. Hypothermia:Prognosis • Dependant upon • Core body temperature • Co-morbidities

21. Hypothermia:Treatment & Interventions • ABC’s – must stabilize • What interventions will you perform initially? • What do you think the goal of treatment is? • How would you achieve this goal? Next

22. Hypothermia:Treatment & Interventions • Goal: • Rewarming to temp of 95˚F • Correction of dehydration & acidosis • Treat cardiac dysrhythmias • Attainment: • Passive & active external rewarming • What are some examples? • Passive – move to warm place & dry place remove wet clothes, apply warm blankets • Active -- body to body contact, fluid or air filled blankets, • Active core rewarming • warm IV fluids, heated humidified O2, • peritoneal , gastric or colonic lavage What should be warmed first – core or extremities? Why?

23. Hypothermia:Treatment & Interventions • Monitor • Core temp • for marked vasodilatation & hypotension • After drop • What is this? • Teach • Warm clothes & hats, layers, high calorie foods, planning

24. Hypothermia:Interdisciplinary Management • Who would be involved in this client’s care? • RN • MD • PT/OT • SW • CM • RT

25. Submersion Injury:Causes & Incidence • 8000 submersion injuries per year • 40% children under 5yrs • Categorized as • Drowning • Near drowning • Immersion syndrome • Risk factors • Inability to swim & entanglement with objects in water • ETOH or drug use • Trauma • Seizures • Stroke Next

26. Submersion Injury :Pathophysiology • Definition • Drowning • Death from suffocation after submersion in water or other fluid medium • Near Drowning • Survival from potential drowning • Immersion syndrome • Immersion in cold water  stimulation of vagus nerve & potentially fatal dysrhythmias (bradycardia)

27. Submersion Injury :Pathophysiology • Death is caused by hypoxia • Victims that aspirate • secondary to aspiration & swallowing of fluid • fluid aspirated into pulmonary tree  PULMONARY EDEMA - HYPOXIA • Victims that do not aspirate • bronchospasm & airway obstruction  “dry drowning” - HYPOXIA

28. Submersion Injury :Manifestations & Complications • What will your patient look like? • Pulmonary • Cardiac • Neuro

29. Submersion Injury :Manifestations & Complications • Dependant upon length of time & amount of aspirate • Pulmonary • Ineffective breathing, dyspnea, distress, arrest, crackles & rhonchi, pink frothy sputum with cough, cyanosis • What interventions would you perform? • Cardiac • Inc./dec. HR, dysrhythmia, dec. BP, cardiac arrest • Neuro • Panic, exhaustion, coma

30. Submersion Injury :Treatment & Interventions • ABC’s – must stabilize • What interventions will you perform initially? • What should you assume with all victims? • What do you think the goal of treatment is? • How would you achieve this goal? Next

31. Submersion Injury :Treatment & Interventions • Goal: • Correct • hypoxia • acid/base balance • fluid imbalances • correct dysrhythmias • Attainment: • Anticipate intubation • 100% O2 via non-rebreather • IV access • Near drowning victims: • Nursing assessment • Pulmonary Edema • SPO2

32. Submersion Injury :Interdisciplinary Management • Who would be involved in this client’s care? • RN • MD • RT • SW • Chaplain

33. Bites & Stings:Pathophysiolgy • Direct tissue damage is a product of • Animal size • Characteristics of animal’s teeth • Strength of jaw • Toxins released • Death is due to • Blood loss • Allergic reactions • Lethal toxins

34. Poisoning: • 1-800-221-1212 • Treatments: • Activated charcoal, gastric lavage, eye/skin irrigation, hemodialysis, hemoperfusion, urine alkalinization, chelating agents and antidotes – acetylcysteine (Mucomyst) • Contraindicated (charcoal & gastric lavage): • AMS, ileus, diminished bowel sounds, ingestion of substance poorly absorbed by charcoal (alkali, lithium, cyanide)

35. Agents of Terrorism:Types • Bioterrorism • Anthrax, plague, tularemia, smallpox, botulism, hemorrhagic fever • Chemical terrorism • Sarin, phosgene, mustard gases • Radiological/Nuclear terrorism

36. Tularemia Plague

37. Agents of Terrorism:Treatment • Bioterrorism • Anthrax, Plague, Tularemia • Treatment: antibiotics (streptomycin or gentamicin) • Smallpox • Treatment: vaccine • Botulism • Treatment: antitoxin • Hemorrhagic fever • Treatment: no established treatment Provided there is sufficient supply & treatment occurs in a timely manner!!!!!!!

38. Agents of Terrorism:Treatments • Chemical Terrorism • Sarin gas • Nerve gas (highly toxic) • Can cause death within minutes of exposure – paralyzing respiratory muscles • Treatment: antidote – atropine & 2-PAM chloride • Phosgene gas • Colorless gas • Can cause respiratory distress, pulmonary edema & death • Treatment: treat S/S, remove from exposure • Mustard gas • Yellow/brown in color , garlic like odor • Can irritate eyes, burn skin and creates blisters, damage lungs if inhaled • Treatment: decontamination, treat symptoms

39. Agents of Terrorism:Treatments • Radiologic/Nuclear Terrorism • Radiologic dispersal devices (RDD’s) • Aka: dirty bombs • Made of explosives & radioactive material • When detonated: smoke & radioactive dust enter air • Treatment: limit contamination (cover mouth & nose) & decontamination (shower, proper disposal of clothing) • Ionizing radiation (nuclear) • Acute radiation syndrome (ARS) • External radiation exposure

40. Radiologic/Nuclear Terrorism(FYI) • American Nuclear Society: • Extremity (arm, leg, etc) Xray: 1 mrem • Dental Xray: 1 mrem • Chest Xray: 6 mrem • Nuclear Medicine (thyroid scan): 14 mrem • Neck/Skull Xray: 20 mrem • Pelvis/Huip Xray: 65 mrem • CAT Scan: 110 mrem • Upper GI Xray: 245 mrem • Barium Enema: 405 mrem • A single dose of around 300,000-500,000 mrem is usually considered produce death in 50% of the cases.

41. Bioterrorism:Interdisciplinary Management • Who would be involved in this client’s care? • EVERYONE

42. Emergency Nursing • Triage • Rapid assessment skill to determine acuity • Threat to life, vision, or limb are treated before other patients

43. Emergency Nursing- Primary Survey • Airway, breathing, circulation, and disability (ABCD) • Identifies life-threatening conditions • Necessary interventions started immediately before proceed to next step of the survey

44. Primary Survey • Airway with cervical spine stabilization and/or immobilization • Signs/symptoms of compromised airway • Dyspnea • Inability to vocalize • Presence of foreign body in airway • Trauma to face or neck (See Notes below for Primary Survey)

45. Primary Survey • Maintain airway: Least to most invasive method • Open airway using the jaw-thrust maneuver

46. Primary Survey • Maintain airway: Least to most invasive method cont. • Suction and/or remove foreign body • Insert nasopharyngeal/oropharyngeal airway • Endotracheal intubation • Cricothyroidotomy or tracheostomy

47. Primary Survey • Stabilize/immobilize cervical spine: Face, head, or neck trauma and/or significant upper torso injuries • * Remember* Cervical Spine Stabilization is always part of the primary survey!!!

48. Primary Survey • Breathing: Assess for dyspnea, cyanosis paradoxic/asymmetric chest wall movement, decreased/absent breath sounds, tachycardia, hypotension • Administer high-flow O2 via a nonrebreather mask • Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions • Monitor patient response

49. Primary Survey • Circulation: Check central pulse (peripheral pulses may be absent because of injury or vasoconstriction) • Assess skin for color, temperature, moisture • Assess mental status and capillary refill • Insert two large-bore IV catheters • Initiate aggressive fluid resuscitation using normal saline or lactated Ringer’s

50. Primary Survey • Disability: Measured by patient’s level of consciousness • AVPU • A = alert • V = responsive to voice • P = responsive to pain • U = unresponsive • Glasgow Coma Scale: Assess arousal aspect of patient’s consciousness (EVM) **Note** • Pupils: Size, shape, response to light, equality